Hand and Wrist checklist

Rules:

1. Look, feel and move :)
2. We don’t say abnormal until we compare right and left!

WIPPER and the intro

• Introduce yourself and shake hands
• Washing of hands and appropriate hand hygiene
• Asking for permission
• Ensuring the room’s privacy
• Ensuring the environmental warmth and good lighting conditions
• Asking for appropriate exposure (One joint above, one joint below)
• Asking the patient to be in the appropriate position (Sitting upright with a pillow under his hands)
• Relocating to the right side of the patient
• Asking for a chaperon
• “I have all of my equipment’s”

Vital signs:

• Make sure you know the 6 vital signs

Look

Look at the palm, dorsum, lateral sides of the hands and in between fingers.

• No scars, skin rash, no bruises :)
• No color changes; palmar erythema, (raynaud’s syndrome)
• No nail changes; nail pitting/brittle nails …
• No deformities; Swan neck / boutonnière/ mallet / Trigger finger / Sausage fingers / dupuytren’s contractures (Alcoholic-CLD) / Z thumb (RA) / Ulnar deviation (RA)
• No skin nodules ~ Bouchard’s/Heberden’s (Osteoarthritis)
• No gouty tophi
• No visible soft tissue swelling
• No muscle wasting (thenar wasting in carpal tunnel syndrome)/ hypertrophy / fasciculations
• While looking at the hand’s fingertips, mention No Calcinosis (Systemic Sclerosis)
• Ask the patient to form a fist, mention No loss of “Hill-Valley-Hill-Valley” on the dorsal aspect of the hand (RA)

Look at the patient’s elbow

• Comment on “No rheumatoid nodules”

Feel

• Palpate dorsum of the hand to check for temperature/dryness and sweatiness (and comment)
• Pinch the skin of the dorsal aspect of the hand, mention No thick nor tightening of the skin found (Scleroderma-Rodnan score)

Scleroderma-Rodnan Score

• Check all other joints for soft tissue swelling and fluctuations using your 2 thumbs (Wrist joint, MCP, PIP, DIP, don’t forget the thumb’s 2 joints!)
• Squeeze test ~ squeeze all MCP joints for tenderness

Move

• Give the patient 2 fingers and ask him to squeeze to assess power of his hands
• Comment on normal power
• Ask the patient to move his wrist in all 4 directions to assess range of motion in his wrist
• Comment on full range of motion
• Ask the patient to move his thumb in all directions to assess its range of motion, and ask him to move it against resistance too.
• Ask the patient to count their fingers (MCP joint flexion maneuver)
• Test flexor digitorum profundus (isolate each finger, and ask to do flexion on DIP (extend pip)) and flexor digitorum superficialis (isolate each finger, and ask to do flexion on PIP (extend MCP))
• Ask the patient to form a semi fist and make sure his fingers point towards scaphoid bone
• Finkelstein’s test; ask the patient to make fist with thumb tucked inside, then ask him to do ulnar deviation. Positive test: pain above the radial side of the hand. De Quervain’s tenosynovitis

Nerves

Median nerve

• For motor, ask the patient to do “Ok sign” this is only testing the anterior interosseous branch of median, that’s why we need a test for median proper, next step for that.
• After patient does the “Ok sign”, assess its power by trying to pull on his ok sign after asking him to resist.

Ok sign and anterior interosseous syndrome

• To test median nerve proper, we do opposition test of thumb (Oppose thumb and little finger)
• For sensory, ask the pt to close his eyes, palpate thenar eminence and ask if patient felt it.

Ulnar nerve

• For motor, ask the patient to abduct and adduct his fingers (scissoring). Also,
  Adduction power can be assessed by putting a paper between patient’s finger (Ask him to not let it go) and trying to pull it.
  Abduction power can be assessed by:

Ulnar - abduction testing

Scissoring

• For sensory, ask the pt to close his eyes, palpate hypothenar eminence and ask if patient felt it

Radial nerve

• For motor, ask the patient to extend his fingers at (MCP joint) ask the patient to lay hand flat on a table, and raise only the fingers. (Then against resistance for power assessment)

• For sensory, ask the pt to close his eyes, palpate dorsum of the hand on the lateral half

Carpal tunnel syndrome (3 tests);

1. Carpal Compression Test (most sensitive); compress with your thumb the position of the median nerve (Proximal to the distal hand crease) for 1 minute, this should (If the nerve is compressed) trigger the compression thus causing signs of carpal tunnel syndrome (Pain, Paresthesia and Numbness on the lateral 3.5 fingers) aka Durkan’s test

2. Tinel’s test; tap the position of the median nerve (Proximal to the distal hand crease) for 1 minute, this should (If the nerve is compressed) trigger the compression thus causing signs of carpal tunnel syndrome (Pain, Paresthesia and Numbness on the lateral 3.5 fingers)

3. Phalen’s test; (Reverse prayer) for 1 minute, a positive test again will produce symptoms of carpal tunnel syndrome (Pain, Paresthesia and Numbness on the lateral 3.5 fingers)

End your exam by:

• Mention doing a neurovascular check
• Mention doing capilaary refill test
• Mention assessing radial pulse